Cost-effectiveness of rotavirus vaccination and predictors of diarrheal disease in children during a complex humanitarian emergency Open Access

Gargano, Lisa (2012)

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Background: A complex humanitarian emergency (CHE) involves a complete breakdown of authority that goes beyond the mandate or response capacity of any single country or United Nations agency. Diarrheal diseases are often a principal cause of morbidity and mortality in children under five during a CHE. Rotavirus causes up to 40% of diarrhea cases in Africa. Two vaccines for rotavirus are safe and effective in children. The goal of the first aim of this thesis was to assess if rotavirus vaccination would be cost-effective during a CHE. The goal of the second aim was to determine correlates of diarrhea disease in children under five in Somalia.

Methods: A cost-effectiveness analysis was performed comparing no vaccine, one-dose, or two-doses of rotavirus vaccine. A univariate sensitivity analysis was carried out to examine the extent to which the uncertainty in the variables affects our estimates. An incremental cost-effectiveness ratio (ICER) to compare no vaccination to one- or two-doses of rotavirus vaccine was performed. For aim two, data was from the 2005-2006 MICS3. The outcome was diarrhea among children under five in past two weeks. Variables included child's age, gender, vitamin A receipt, measles vaccination, polio vaccine, any vaccine, vaccine refusal, breastfeeding, maternal hygiene behaviors, and water treatment.

Results: Variables influencing the ICER most were vaccine effectiveness and access to outpatient and inpatient care. Rotavirus vaccination would avert up to 12,469 deaths and would save $71,124 in medical treatment costs. The base-case ICER was $17.76 per life saved. For aim two, in the unadjusted analysis, gender, age, measles/MMR vaccine, receipt of any vaccine, washing hands before feeding child, and washing hands after cleaning baby's bottom were all associated with diarrheal disease. The final model consisted of age, gender, receipt of any vaccine, and washing hands after cleaning baby's bottom. The kappa statistic for the model's ability to predict a case was 0.1304. Conclusions: Rotavirus vaccination is a "very cost-effective" intervention, as defined by WHO as ≤1 per captia GDP (Somalia $220.30). Targeted interventions to prevent diarrheal diseases in children under five during a CHE should focus on vaccination and maternal hygiene behaviors.

Table of Contents

Table of Contents

Chapter I: Introduction...1 Chapter II: Review of the Literature...3 Complex humanitarian emergency...3 Rotavirus and rotavirus vaccine...3 Burden of rotavirus disease...5 Mortality...6 Morbidity - Hospitalization...6 Mortality and burden of rotavirus disease - Countries with experience of CHE...7 Cost-effectiveness analysis...8 Cost-effectiveness analysis for rotavirus vaccination...8 Mass vaccination campaigns...9 Success of mass vaccination campaigns...10 Predictors of diarrheal disease...11 Somalia context...11 Conclusions...11 Chapter III: Methodology...13 Aim 1. To examine the cost-effectiveness of rotavirus vaccination during a CHE...13 Aim 2. To determine the predictors of diarrheal disease in children under five in Somalia...16 Chapter IV: Results...21 Aim 1. To examine the cost-effectiveness of rotavirus vaccination during a CHE...21 Baseline scenario...21 Univariate sensitivity analysis...21 Aim 2. To determine the predictors of diarrheal disease in children under five in Somalia...23 Characteristics of children under five with and without diarrhea...23 Model 1 - unadjusted ORs...23 Model 2 - backward elimination...24 Model 3 - forward elimination...24 Final model...24 Summary...25 Chapter V: Discussion...26 Introduction...26 Aim 1. To examine the cost-effectiveness of rotavirus vaccination during a CHE...26 Summary and Conclusions...26 Limitations and Delimitations...28 Aim 2. To determine the predictors of diarrheal disease in children under five in Somalia...28 Summary and Conclusions...28 Limitations and Delimitations...30 Implications and Recommendations...31 References...32 Tables and Figures...37 Figure 1. Decision tree...37 Table 1. MICS3 variable names and questions...38 Table 2. Rotavirus-related events or costs with and without rotavirus vaccine and averted by vaccination...39 Figure 2. Tornado diagram of univariate sensitivity analysis...40 Table 3. Sensitivity analysis for one dose...41 Table 4. Sensitivity analysis for two doses...42 Table 5. Distribution of variables by presence or absence of diarrhea in last two weeks...43 Table 6. Distribution of different treatments for diarrhea...44 Table 7. Unadjusted odds ratios for potential predictors of diarrheal disease...45 Table 8. MLE beta values and Kappa statistic for the three models...46

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